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Truong P, Mazzolai L, Font C, Ciammaichella M, González-Martínez J, Tufano A, Gavín-Sebastián O, Le Mao R, Monreal M, Hugli O. Safety of the pulmonary embolism rule-out criteria rule: Findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. Acad Emerg Med 2023; 30:935-945. [PMID: 37092646 DOI: 10.1111/acem.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/29/2023] [Accepted: 04/20/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The diagnostic strategy for pulmonary embolism (PE) includes a D-dimer test when PE probability is low or intermediate, but false-positive D-dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule-out criteria (PERC) rule excludes PE without D-dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. METHODS This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC-negative (PERC-N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC-N versus PERC-positive (PERC-P) patients at 3 months. RESULTS From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC-N with a failure rate of 0.7% (95% confidence interval 0.6%-0.8%). PERC-N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC-N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3-month follow-up. CONCLUSIONS A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE.
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Affiliation(s)
- Perrine Truong
- Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lucia Mazzolai
- Department of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Carme Font
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | | | - José González-Martínez
- Department of Internal Medicine, Hospital Universitari Sant Joan de Déu, Fundació Althaia, Manresa, Barcelona, Spain
| | - Antonella Tufano
- Regional Reference Centre, Federico II University Hospital, Naples, Italy
| | - Olga Gavín-Sebastián
- Department of Haematology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Raphael Le Mao
- Department of Internal Medicine, CHRU Brest, Brest, France
| | - Manuel Monreal
- Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Olivier Hugli
- Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Sprockel Diaz JJ, Veronesi Zuluaga LA, Coral Coral DC, Fierro Rodriguez DM. Application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-Dimer in patients undergoing computed tomography pulmonary angiography for diagnosis of pulmonary embolism. J Vasc Bras 2023; 22:e20220022. [PMID: 37143505 PMCID: PMC10153795 DOI: 10.1590/1677-5449.202200222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 01/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background Diagnosis of pulmonary embolism (PE) constitutes a challenge for practitioners. Current practice involves use of pre-test probability prediction rules. Several strategies to optimize this process have been explored. Objectives To explore whether application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-dimer (DD) would have reduced the number of computed tomography pulmonary angiography (CTPA) examinations performed in patients with suspected PE. Methods A retrospective cross-sectional study of adult patients taken for CTPA under suspicion of PE in 2018 and 2020. The PERC rule and age-adjusted DD were applied. The number of cases without indications for imaging studies was estimated and the operational characteristics for diagnosis of PE were calculated. Results 302 patients were included. PE was diagnosed in 29.8%. Only 27.2% of 'not probable' cases according to the Wells criteria had D-dimer assays. Age adjustment would have reduced tomography use by 11.1%, with an AUC of 0.5. The PERC rule would have reduced use by 7%, with an AUC of 0.72. Conclusions Application of age-adjusted D-dimer and the PERC rule to patients taken for CTPA because of suspected PE seems to reduce the number of indications for the procedure.
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Affiliation(s)
- John Jaime Sprockel Diaz
- Fundación Universitaria de Ciencias de la Salud - FUCS, Bogotá, Colombia
- Hospital de San José - HSJ, Bogotá, Colombia
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Schiebler ML, Fain S, van Beek E. Vascular imaging of the lung: perspectives on current imaging methods. Br J Radiol 2022; 95:20200759. [PMID: 32795175 PMCID: PMC9153715 DOI: 10.1259/bjr.20200759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This commentary will discuss the use of advanced non-invasive imaging methodology for the pulmonary vascular system with special attention to a rubric for the imaging and clinical team to use for any particular clinical situation.
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Affiliation(s)
- Mark L. Schiebler
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean Fain
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Edwin van Beek
- SINAPSE Chair of Clinical Radiology, Director Edinburgh Imaging facility QMRI, Honorary Consultant Radiologist, NHS Lothian Health Board, CO.19 Edinburgh Imaging, Queen’s Medical Research Institute, Edinburgh Bioquarter, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom
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Kothare A, Abahussain M, Svirkov-Vainberg N, O'Kelly P, Nfila G, Gilligan P. A retrospective application of the pulmonary embolism rule out criteria (PERC) of the American College of Physicians would reduce the number of CTPAS by 6% without a false negative in an Irish hospital. Ir J Med Sci 2020; 190:1189-1193. [PMID: 33090350 DOI: 10.1007/s11845-020-02398-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Internationally, the number of computerised tomographic pulmonary angiographies (CTPAs) being performed to rule out pulmonary embolism (PE) has caused some concern. AIM This study was performed to assess if the application of Pulmonary Embolism Rule-out Criteria (PERC) in an Irish Emergency Department (ED) would have helped to safely reduce the number of D-dimer assays and computed tomographic pulmonary angiographies (CTPAs) ordered. METHODS The PERC was retrospectively calculated in all patients who underwent CTPA for possible PE. It was then established if the application of the PERC as per the American College of Physicians' (ACP) guidelines would have safely ruled out the need for further imaging. RESULTS Of the 529 patients who underwent CTPA in the study, 63 patients (12%) had PE on CTPA. Had the PERC criteria been applied, no patient who had a PE would have been missed. In this study, PERC had 100% sensitivity and 14% specificity. DISCUSSION/CONCLUSION Application of the PERC rule, as per the ACP guidelines, would have reduced the number of CTPAs performed by 32 (6%) without missing any patient with a proven pulmonary embolus.
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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71:e59-e109. [PMID: 29681319 DOI: 10.1016/j.annemergmed.2018.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Glober N, Tainter CR, Brennan J, Darocki M, Klingfus M, Choi M, Derksen B, Rudolf F, Wardi G, Castillo E, Chan T. The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism. Am J Emerg Med 2018; 37:895-901. [PMID: 30104092 DOI: 10.1016/j.ajem.2018.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022] Open
Abstract
We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli). Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer. Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE. In our cohort, a DAGMAR Score < 2 equated to overall PE risk < 1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results. By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.
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Affiliation(s)
- Nancy Glober
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Christopher R Tainter
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America
| | - Jesse Brennan
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Mark Darocki
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Morgan Klingfus
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America
| | - Michelle Choi
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Brenna Derksen
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Frances Rudolf
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Gabriel Wardi
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Edward Castillo
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Theodore Chan
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
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Glober N, Tainter CR, Brennan J, Darocki M, Klingfus M, Choi M, Derksen B, Rudolf F, Wardi G, Castillo E, Chan T. Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department. J Emerg Med 2018; 54:585-592. [PMID: 29502865 DOI: 10.1016/j.jemermed.2018.01.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 01/07/2018] [Accepted: 01/21/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging. OBJECTIVE Our objective was to examine the test characteristics of the high-sensitivity d-dimer for the diagnosis of PE at our institution and evaluate use of the d-dimer and factors associated with a falsely elevated d-dimer. METHODS We retrospectively collected data on adult patients evaluated with a d-dimer and computed tomography (CT) pulmonary angiogram or ventilation perfusion scan at two EDs between June 4, 2012 and March 30, 2016. We collected symptoms (dyspnea, unilateral leg swelling, hemoptysis), vital signs, and medical and social history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, chronic obstructive pulmonary disease, smoking). We calculated test characteristics, including sensitivity, specificity, and likelihood ratios for the assay using conventional threshold and with age adjustment, and performed a univariate analysis. RESULTS We found 3523 unique visits with d-dimer and imaging, detecting 198 PE. Imaging was pursued on 1270 patients with negative d-dimers, revealing 9 false negatives, and d-dimer was sent on 596 patients for whom negative Pulmonary Embolism Rule-Out Criteria (PERC) were documented with 2% subsequent radiographic detection of PE. The d-dimer showed a sensitivity of 95.7% (95% confidence interval [CI] 91-98%), specificity of 40.0% (95% CI 38-42%), negative likelihood ratio of 0.11 (95% CI 0.06-0.21), and positive likelihood ratio of 1.59 (95% CI 1.53-1.66) for the radiographic detection of PE. With age adjustment, 347 of the 2253 CT scans that were pursued in patients older than 50 years with an elevated d-dimer could have been avoided without missing any additional PE. Many risk factors, such as age, history of PE, recent surgery, shortness of breath, tachycardia and hypoxia, elevated the d-dimer, regardless of the presence of PE. CONCLUSIONS Many patients with negative d-dimer and PERC still received imaging. Our data support the use of age adjustment, and perhaps adjustment for other factors seen in patients evaluated for PE.
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Affiliation(s)
- Nancy Glober
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Christopher R Tainter
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Jesse Brennan
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Mark Darocki
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Morgan Klingfus
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Michelle Choi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Brenna Derksen
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Frances Rudolf
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Edward Castillo
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Theodore Chan
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
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Swartz J, Koziatek C, Theobald J, Smith S, Iturrate E. Creation of a simple natural language processing tool to support an imaging utilization quality dashboard. Int J Med Inform 2017; 101:93-99. [PMID: 28347453 DOI: 10.1016/j.ijmedinf.2017.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/10/2017] [Accepted: 02/18/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Testing for venous thromboembolism (VTE) is associated with cost and risk to patients (e.g. radiation). To assess the appropriateness of imaging utilization at the provider level, it is important to know that provider's diagnostic yield (percentage of tests positive for the diagnostic entity of interest). However, determining diagnostic yield typically requires either time-consuming, manual review of radiology reports or the use of complex and/or proprietary natural language processing software. OBJECTIVES The objectives of this study were twofold: 1) to develop and implement a simple, user-configurable, and open-source natural language processing tool to classify radiology reports with high accuracy and 2) to use the results of the tool to design a provider-specific VTE imaging dashboard, consisting of both utilization rate and diagnostic yield. METHODS Two physicians reviewed a training set of 400 lower extremity ultrasound (UTZ) and computed tomography pulmonary angiogram (CTPA) reports to understand the language used in VTE-positive and VTE-negative reports. The insights from this review informed the arguments to the five modifiable parameters of the NLP tool. A validation set of 2,000 studies was then independently classified by the reviewers and by the tool; the classifications were compared and the performance of the tool was calculated. RESULTS The tool was highly accurate in classifying the presence and absence of VTE for both the UTZ (sensitivity 95.7%; 95% CI 91.5-99.8, specificity 100%; 95% CI 100-100) and CTPA reports (sensitivity 97.1%; 95% CI 94.3-99.9, specificity 98.6%; 95% CI 97.8-99.4). The diagnostic yield was then calculated at the individual provider level and the imaging dashboard was created. CONCLUSIONS We have created a novel NLP tool designed for users without a background in computer programming, which has been used to classify venous thromboembolism reports with a high degree of accuracy. The tool is open-source and available for download at http://iturrate.com/simpleNLP. Results obtained using this tool can be applied to enhance quality by presenting information about utilization and yield to providers via an imaging dashboard.
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Affiliation(s)
- Jordan Swartz
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States.
| | - Christian Koziatek
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States
| | - Jason Theobald
- Department of Emergency Medicine, Mount Sinai West Hospital, Mount Sinai St Luke's Hospital, New York, NY, United States
| | - Silas Smith
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States
| | - Eduardo Iturrate
- New York University School of Medicine, Department of Internal Medicine, New York, NY, United States
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Mountain D, Keijzers G, Chu K, Joseph A, Read C, Blecher G, Furyk J, Bharat C, Velusamy K, Munro A, Baker K, Kinnear F, Mukherjee A, Watkins G, Buntine P, Livesay G, Fatovich D. RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates. PLoS One 2016; 11:e0166483. [PMID: 27918576 PMCID: PMC5137866 DOI: 10.1371/journal.pone.0166483] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/28/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. AIMS To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. METHODS A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. RESULTS Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. DISCUSSION/ CONCLUSIONS We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.
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Affiliation(s)
- David Mountain
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Gerben Keijzers
- Emergency Medicine Department, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Kevin Chu
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Anthony Joseph
- Emergency Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Catherine Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Respiratory Medicine Unit (Research, Pleural Diseases) Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Gabriel Blecher
- Emergency Medicine, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Chrianna Bharat
- Statistical Support, Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - Karthik Velusamy
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Andrew Munro
- Emergency Department, Nelson Hospital, Nelson, New Zealand
| | - Kylie Baker
- Emergency Medicine, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Frances Kinnear
- Emergency Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Ahses Mukherjee
- Emergency Medicine, Armadale General Hospital, Perth, Western Australia, Australia
| | - Gina Watkins
- Emergency Medicine, Sutherland Hospital and Community Health Centres, Caringbah, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Georgia Livesay
- Emergency Medicine Research, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
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